Laserfiche WebLink
PERMITTEE NAME/ADDRESS(lndudeF«UuyNwnelL atiu ifD,,f•nnr! <br />NAME ,iter i'. ,.,,7 �. <br />ADDRESS 0 At,' 1 1 7 ii <br />176 5iiuY1;ii C},;iIVr; <br />FACILITY j1 Yt i(1 D I: fi <br />LOCATION <br />7'IT tirll:I. 'AY, p,r^Zt�'�;'r <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Ap--oved. <br />DISCHAR( filTORING REPORT (DMR) OMB,N 4Q-0004, <br />(2-10 (17-19) i< L+%i i'i' <br />c n . DISCHARGE (• ; I ti r :; k) Approv } spires OS -31 98 <br />PaPERMIT NUMBER N <br />'UMBER F r ? �; n ., <br />MONITORING PERIOD <br />YEAR MO I DAY [YEAR MO DAY <br />FROM it'd X11 7j TO �'; i.: yT :;:e;n;; t;T .I. ;.,r.; j! ::•::i- <br />(20-21) (22-23) (24-25) (26-271 (28-29) (30-311 NOTE: Read instructions before completing this form. <br />PARAMETER <br />(3 Card Only) QUANTITY OR LOADING <br />(4 Card Only) QUANTITY OR CONCENTRATION <br />NO• <br />FREQUENCY <br />SAMPLE <br />(46-53) (54-61) <br />(36-45), (46-53 (5461) <br />OF <br />(32-371 <br />>< <br />EX <br />AN4- <br />TYPE <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS <br />162.611 <br />/54 68)66) <br />/69-701 <br />J I L A ii i) 'v is E A S F <br />SAMPLE <br />;- rc n .;c (I;c <br />9 4 j <br />4 u ;r : • . <br />: I;: c;c <br />�... S; ' <br />vr:;uAL <br />MEASUREMENT <br />S4U6b i 0 J <br />PERMIT <br />{, <br />i is <br />! ' E. [) I' f,' 1 R } <br />REQUIREMENT <br />r tq <br />�• <br />1. <br />, <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />/r <br />PERMIT <br />,f <br />REQUIREMENT <br />SAMPLE <br />t <br />MEASUREMENT+1` <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />t <br />� <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />f <br />SAMPLE <br />' <br />MEASUREMENT <br />PERMIT" <br />REQUIREMENT <br />,= <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND <br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON <br />MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />'Z <br />TELEPHONE <br />DATE <br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS <br />TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE <br />k I f <br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br />V 7 <br />'? �,tl <br />�•' <br />' <br />' <br />SIGNATURE OF PRIN IPAL EXECUTIVE <br />OFFICER OR AUTHORIZED AGENT <br />THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. S 1001 AND 33— <br />U.Sdt* <br />.C. S 1318. (Fen* under dwas statutes msy kwA4e es upto $ 10,000 <br />uWormacimurn inpdeaenentofbetween 6monasend 5yesn.l <br />r `J / i ( <br />+ <br />f <br />TYPED OR PRINTED <br />AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a// attachments here) <br />S.,TI'LEABLE SOLIDS LIMI-1 APPLIES D;iLY IF C= •1U.-Y.R, 24 -KR PP. 1' CL)tI!�;:.' <br />r. <br />T3�i E IItDN L11IT4 1 L L ,ID 9 kPi''LI.G TD IR RPAIR T;;D '� SO ,. C » 7. 1 <br />T C iYj� /'. • • i. fti s r.t'i r1 i • �• r <br />EPA Form'3320-1 r106-95) ' Previous edltions'may be used. ` ' ' '' ' (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br />